Curb Ramp Procedures and Request Form

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mallyl ifis County of Hawaii DEPARTMENT OF PUBLIC WORKS ENGINEERING DIVISION CURB RAMP REQUEST FORM This form is to be filled out by or on behalf of a person with a disability who requires the installation of new curb ramps or modifications to existing curb ramps and /or the modification of existing accessible path(s) leading to the curb ramps within the County road right -of -way. Fill out this form as completely as possible or call 961 -8327 (voice) for assistance. Provide a written description and /or indicate on the sketch shown below describing the location(s) where curb ramps and /or modifications are needed. Within two (2) weeks of receiving this request, a representative from the Department of Public Works, Engineering Division will be contacting the requestor to validate the request and /or confirm the information that has been provided and /or to schedule an onsite meeting with the requestor to validate /confirm the request. The requester will then be notified whether his request has been accepted or rejected for construction. Date: Name of Person Requesting Curb Ramp(s) /Modification(s): Contact Person (if different from above): Address /Tax Map Key Address /Tax Map Key Phone: ❑ ❑ Address: City: Zip: Street Name Enter the location of your request and use sketch to the right. Street Names: Address /Tax Map Key Address /Tax Map Key Tax Map Key: Address ( es ) Please mark location of E co z curb ramp(s) with an "X" in Describe the curb ramp work you are requesting. Provide a brief statement of why you are making this request. This information may be used to prioritize requests. Return to: Engineering Division or Fax to: (808) 961 -8933 Department of Public Works 101 Pauahi St., Ste. 7 Hilo, HI 96720 0 ACCEPTED Date Received: 0 REJECTED BY: REQUEST NO.: County of Hawaii is an Equal Opportunity Provider and Employer